# Breathless after a road accident in a 24-year-old: a live trauma case

> A live emergency case for medical students: a young rider getting more breathless after a road accident. The primary survey, chest injuries that kill early, red flags and the first tests.

- Emergency Medicine · Intermediate · about 20 minutes · live emergency
- Web page: https://www.medikarya.in/case-studies/24-year-old-man-struggling-to-breathe-after-a-bike-accident
- Work up this patient: https://www.medikarya.in/case-studies/24-year-old-man-struggling-to-breathe-after-a-bike-accident

## How the patient presents

A delivery rider came off his motorbike when a car hit him about half an hour ago. He hit the road on his right side and is getting more and more breathless.

## Why breathlessness after chest trauma matters

Chest injuries kill through a few problems that can be found by examining the patient and fixed at the bedside, often before any scan. The skill is a primary survey done in order, treating each problem as you find it and then looking again.

## What to ask in the history

- How the accident happened: speed, what hit him, whether he wore a helmet, how he landed
- Time since the injury, and whether the breathlessness is getting worse
- Chest pain: where it is, and whether it is worse on breathing in
- Other injuries: head (did he black out), neck, abdomen, pelvis, limbs
- Coughing up blood
- Past illness, regular medicines (especially blood thinners), allergies, when he last ate

## Red flags

- Breathlessness or breathing rate getting worse
- Falling oxygen saturation
- Fast pulse, low blood pressure, cold clammy skin
- Breath sounds absent or reduced on one side
- The windpipe pushed to one side, or distended neck veins
- Part of the chest wall moving the wrong way with breathing
- Agitation, confusion or drowsiness

## What to examine

- Primary survey in order: airway with the neck protected, breathing, circulation, disability, exposure
- Chest: look for bruising, wounds and uneven movement; feel for tenderness, crackling under the skin and rib movement
- Percussion and breath sounds on each side; position of the trachea; neck veins
- Circulation: pulse, blood pressure, capillary refill, and every place he could be bleeding (chest, abdomen, pelvis, long bones, outside)
- Conscious level and pupils
- Full exposure, keeping him warm, and a log roll to see his back

## First investigations

- Continuous monitoring of oxygen saturation, pulse and blood pressure
- Blood gas
- Chest X-ray in the resuscitation room, without delaying treatment the examination already calls for
- Bedside ultrasound of the chest and abdomen (eFAST)
- Full blood count, blood group and crossmatch, clotting, kidney function
- CT once he is stable enough to travel

## Differential diagnosis of breathlessness after chest trauma

Grouped, not ranked. Which one fits this patient is for you to work out in the case.

### Air in the chest

- Tension pneumothorax
- Simple pneumothorax
- Open (sucking) chest wound

### Blood in the chest

- Haemothorax
- Massive haemothorax
- Cardiac tamponade

### Chest wall and lung

- Rib fractures
- Flail chest
- Pulmonary contusion

### Elsewhere

- Bleeding into the abdomen or pelvis causing shock
- Diaphragm injury
- Airway injury

## Common mistakes

- Sending for an X-ray before treating a problem the examination has already found.
- Looking only at the chest and missing bleeding in the abdomen, pelvis or limbs.
- Under-treating rib pain, so he cannot breathe deeply or cough.
- Not repeating the primary survey after each intervention.

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A study guide for medical students, not medical advice. Follow your institution's protocols in practice.